Urology Grand Rounds: Contemporary Diagnosis and Management of Priapism. Objectives

Urology Grand Rounds: Contemporary Diagnosis and Management of Priapism Dr. Nathan Hoag (R4), Dept. of Urologic Sciences Dr. Lindsay MacHan, Dept. of Radiology March 27, 2013 Objectives! 1. To review the clinical presentation and work up of priapism.! 2. To review the use of radiologic investigations and interventions as they relate to priapism.! 3. To review current and potential medical and surgical treatments of priapism. 1'

Priapism! A pathologic condition of penile erection lasting beyond, or unrelated to sexual stimulation (persisting beyond 4 hours)! ~ 1-1.5 / 100,000 person years! One of the true urologic emergencies! 2 pathologic and clinical sub-types! Low-Flow (Ischemic)! High-Flow (Non ischemic)! Plus Stuttering priapism (recurrent low-flow priapism) Priapism! Condition named after Priapus, the Greek god of fertility.! Classically shown with a disproportionally large and permanent erection.! Description in the literature credited to Hinman Sr in 1914! Hinman Jr proposed increased viscosity, stasis, ischemic theory behind priapism (1960). 2'

Priapism Priapus: Greek god, or a greasy Greek? 68766 Pager goes off It s the ER It s 2:16 AM Hi, is this urology? I ve got this guy here with priapism, what should I do? On call at St. Paul s Hospital (of course) Dr. Finkler has a patient with a 3 day erection after experimenting with some drugs 3'

Case 1- Perils of Pleasure! 43 yo M! my boyfriend injected me with some trimix again, and it s been up for 3 days now! Admits to popping some Viagra, a little bit of cocaine, and crystal meth! PMHx: HIV +, 1 previous visits to ED for priapism (under 6 hours, secondary to ICI), normal erections. Physical Exam! Fully rigid corporal bodies! Turgid glans and corpus spongiosum! ++ Painful! No evidence of trauma! Penile Blood Gases! ph 6.8, pco2 120, po2 6 4'

Priapism: History! Important to elicit:! Duration of erection*! Pain?! Previous hx of priapism and treatment! Use of drugs! History of pelvic/perineal trauma! History of sickle cell disease or other hematological disorder Priapism: Examination! Examine genitalia, perineum, abdomen for signs of malignancy or trauma.! Corpora cavernosa typically affected while spongiosum and glans spared.! Ischemic priapism often displays fully rigid corporal bodies, while non-ischemic tends to be tumescent, but not as rigid (due to preservation of veno-occlusive mechanism) 5'

Diagnostic work-up! From AUA guideline recommendations! CBC (infectious/hematological)! Reticulocyte count (elevated in SCD)! Urine tox screen (if suspected)! Hgb electrophoresis (to r/o SCD)! Penile blood gases! Colour doppler U/S More on these from! Penile arteriography Dr. Machan Typical Blood Gas Values SOURCE Po 2 (mm Hg) Pco 2 (mm Hg) ph Normal arterial blood (room air) Normal mixed venous blood (room air) Ischemic priapism (first corporal aspirate) >90 <40 7.40 40 50 7.35 <30 >60 <7.25 High Flow Normal penis Erection physiology: Controlled by NO/cGMP signaling pathway Incr cgmp Activates GC NO! SM Lue, NEJM 2000;342 6'

Priapism Pathophysiology Low Flow! Results from a derangement in penile hemodynamics.! Veno-occlusive mechanism abnormality! Venous stasis, accumulation of deoxygenated blood! Impaired smooth muscle function, endothelial cell dysfunction, PDE5 dysregulation! Up-regulation of pro-fibrotic growth factors (TGF )! Smooth muscle necrosis, collagen deposition, penile fibrosis, ED* Etiology- Ischemic Priapism! Hematologic (SCD, leukemia, asplenism, EPO, TPN, Fabry s)! Iatrogenic (ICI)! Neoplastic (Bladder/Prostate/Penile vs mets)! Neurologic (SCI, brain tumour, spinal anaesth, syphilis, epilepsy)! Infectious (malaria, rabies, scorpion/spider bites) 7'

Etiology- Medications! -blockers! Anti-coagulants (Heparin, warfarin)! Anti-depressants (Trazodone, SSRIs)! Anti-anxiety (hydroxizine)! Anti-psychotics! Anti-hypertensives (hydralazine, propanolol)! Recreational (alcohol, cocaine, marijuana)! Hormones (T, GNRH)! PDE5i Management! Goal of management: Achieve detumescence and preserve erectile function (prevent fibrosis)! Stepwise treatment algorithm of increasing invasiveness! Concurrent management of any underlying disease! Evidence for treatments largely unclear, heavy reliance on expert opinion and consensus 8'

MANAGEMENT OF PROSTAGLANDIN E 1-INDUCED PROLONGED ERECTIONS FRANKLIN C. LOWE, M.D. JONATHAN P JAROW, M.D. 2013%04%02' From the Departments of Urology, St. Luke s/roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, New York, and The Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina ABSTRACT-Prolonged erections, priapism, secondary to pharmacologic stimulation are usually treated by drainage of the corporeal bodies and irrigation with a sympathomimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75 patients with pharmaco Ily induced (prostaglandin El) prolonged erections were randomized to receive te line, pseudoephedrine, or placebo. Detumescence occurred in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly better than placebo (p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacologically induced prolonged erections. Medical management! Minimal evidence The development of new nonsurgical therapies and advances in surgical therapy has generated increased interest by patients and physicians in the field of impotence. It is estimated that approximately 10 million American males and over 25 percent of men older than seventy-five years are in impotent. 1.2 Since Brindley3 first demonstrated the 1980s that the intracorporeal injection of phenoxybenzamine could produce erections in men, various vasoactive compounds have been used in both the diagnostic evaluation and treatment of impotent men. 4,5 The most commonly utilized agents today are papaverine, phentolamine, and prostaglandin E 1. There are many potential complications associated with pharmacologically stimulated erections. However, the most significant complication is a prolonged erection, or priapism, which is dose-related and most frequently observed in men with neurogenic and psychogenic impotence.6 The incidence of these prolonged erections reported in! Pseudoephedrine not better than placebo! Terbulatine 36-42% vs 12-15% (p < 0.05) in 2 studies, no benefit in 1 study (Govier, J Urol 1994).! Methelyne Blue- 1 small study in 2002, 19/22 resolved with injection of MB. International Journal of Impotence Research (2004) 16, 424 426 the literature ranges from 2 percent to 18 percent.6 The standard therapy for pharmacologically induced prolonged erections is drainage and irrigation of the corpora with sympathomimetic agents.738 Recent reports have suggested that the oral medications, pseudoephedrine and terbutaline, O are effective therapies for the reversal of pharmacologically induced prolonged erections. However, the natural history of pharmacologic erections is not known, and the efficacy of these medications has not been determined in a controlled fashion. The purpose of this study was to determine whether pseudoephedrine or terbutaline were superior to placebo (sodium bicarbonate) in reversing pharmacologically induced prolonged erections. MATERIAL AND METHODS Over a two-year period, 625 consecutive men with erectile dysfunction received an intracorporeal injection of prostaglandin El as part of their evaluation or treatment. The dosage of prostaglandin El ranged from 2 to 20 pg and was 4, 1993, accepted (with revisions): February ADULT urology selected in an effort to avoid prolonged erections.! Possible use as an adjunct, if at all.? For ICI & 2004 Nature Publishing Group All rights reserved 0955-9930/04 $30.00 www.nature.com/ijir Submitted:]anuary 15.1993 Oral terbutaline in the management of pharmacologically induced prolonged erection UROLOGY / 51 JULY1993 I VOLUME 42, NUMBER1 PLACEBO-CONTROLLED STUDY OF ORAL TERBUTALINE AND PSEUDOEPHEDRINE IN MANAGEMENT OF PROSTAGLANDIN E 1-INDUCED PROLONGED ERECTIONS S Priyadarshi International of Impotence ResearchCollege (2004) 16, 424 426 Jaipur, India DepartmentJournal of Urology, SMS Medical & Hospital, & 2004 Nature Publishing Group All rights reserved 0955-9930/04 $30.00 www.nature.com/ijir FRANKLIN C. LOWE, M.D. Prolonged erection and priapism are common complications following intracavernosal injection of JONATHAN P JAROW, M.D. vasoactive agents in the management of erectile dysfunction. It is usually treated by intracorporeal drainage and irrigation with sympathomimetic agents. There is no established oral. To of Urology, St. Luke s/roosevelt Hospital Center and From therapy the Departments study the effect of oral terbutaline on prolonged erection following intracavernosal Columbia injection University of College of Physicians and Surgeons, New York, New York, vasoactive agent, a controlled randomized study was done in 68 patients. Detumescence was Gray School of Medicine of Wake Forest University, and The Bowman achieved in 42 and 15% of the cases with oral terbutaline and placebo, respectively. Results of this Winston-Salem, North Carolina study suggest that an initial trial with oral terbutaline for pharmacologically induced prolonged erection may be successful. International Journal of Impotence Research (2004) 16, 424 426. doi:10.1038/sj.ijir.3901180 ABSTRACT-Prolonged erections, priapism, secondary to pharmacologic stimulation are Published online 4 March 2004 usually treated by drainage of the corporeal bodies and irrigation with a sympath- Oral terbutaline in the management of pharmacologically induced prolonged erection Keywords: priapism; prolonged erection; terbutaline S Priyadarshi Introduction Materials and omimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75 patients with pharmaco Ily induced (prostaglandin El) prolonged erections were randomized to receive te line, pseudoephedrine, or placebo. Detumescence occurred in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly better than placebo (p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacomethods logically induced prolonged erections. Alpha Agonist/Irrigation There has beenmedical a resurgence of interest the field of Jaipur, DuringIndia the last 3 y, 500 men with erectile dysfuncdepartment of Urology, SMS College & inhospital, impotence among both patients and physicians with tion received intracorporeal injection of a bimix The development of new nonsurgical therapies the literature ranges from 2 percent to 18 percent.6 the development of various surgical and nonsurgical solution containing papaverine and chlorpromaand advances in surgical therapy has generated inthe standard therapy for pharmacologically intherapies. Various vasoactive compounds as intrazine, as part ofcreased their interest evaluation and and treatment. by patients physicians The in the duced prolonged erections is drainage and irricorporeal injections have been used in both the dosage rangedfield from 0.1 to 0.5 Patients were of impotence. It isml. estimated that approxigation of the corpora with sympathomimetic st 1 mately 10tomillion American males regarding and overinjection 25 agents.738 diagnostic evaluation and treatment impotence. complications completely evaluated make a diagnosis Prolonged erection and priapism areofcommon following intracavernosal of of men dysfunction. older than seventy-five years are Recent reports have suggested that the oral Pharmacologically induced erections have various the aetiology percent of erectile It included vasoactive agents in the management of erectile Itexamination, is usually treated by serum intracorporeal 1.2 Since Brindley3 first demonstrated in medications, pseudoephedrine and terbutaline, O impotent. potential complications of which the most signifi- dysfunction. history, physical urine analysis, the 1980s that the intracorporeal injection of pheare effective therapies for the reversal of pharmaprolonged erection or priapism.2 The agents. testosterone, prolactin blood biochemistry, pharmadrainagecant andis irrigation with sympathomimetic There is no established oral therapy. To noxybenzamine could produce erections in men, cologically induced prolonged erections. However, incidence erection ranges 2 to cologic erection test and penile duplex ultrasonothe natural various vasoactiveintracavernosal compounds have been used in study the effect ofofprolonged oral terbutaline on from prolonged erection following injection of history of pharmacologic erections is 18% depending upon the type of agent and the graphy with pharmacologic select of not known, and the efficacy of these medications both the diagnostic stimulation evaluation and in treatment 2 vasoactive agent, a controlled randomized study was done in 68 patients. Detumescence amount of dose used. The standard therapy for patients. All patients were4,5observed in the office impotent men. The most commonly utilized has was not been determined in a controlled fashion. The this purpose of this study was to determine whethagents today are papaverine, Those phentolamine, and erection drainage irrigation until full and detumescence occurred. patients achievedsuch in prolonged 42 and 15% of isthe casesand with oralofterbutaline placebo, respectively. Results of er pseudoephedrine or terbutaline were superior prostaglandin E 1. for more than 21 h were the corporal bodies with sympathomimetic agents.3 with fullfor erection persisting 2 study suggest that an initial trial with oral terbutaline pharmacologically induced prolonged to placebo (sodium bicarbonate) in reversing There are many potential complications associthere is no established oral medication although then treated with oral medication, either terbutaline ated with pharmacologically stimulated erections. pharmacologically induced prolonged erections. erection some mayrecent be successful. reports have suggested that pseudoe5 mg or placebo (sodium observedis a However, the bicarbonate) most significant and complication phedrine and terbutaline may be effective in revermaterial AND METHODS for 15 An additional dosage of 5 mg was if International Journal of4,5impotence Research (2004) 16,min. 424 426. prolonged doi:10.1038/sj.ijir.3901180 erection, or priapism, which given is dose-resing such erections. This study was conducted to detumescence lated didandnot 15 min Over a two-year period, 625 consecutive men most occur frequentlyafter observed in menand with Published onlinethe4 efficacy Marchof2004 determine oral terbutaline in pharwith erectile dysfunction received an intracorponeurogenicwith and persistent psychogenic impotence.6 The in30 min. Any patient erection after real injection of prostaglandin El as part of their of these prolonged erections reportedof in macologically induced prolonged erection. 4 h received thecidence standard intracorporeal irrigation evaluation or treatment. The dosage of dilute adrenaline solution. Patients blood pressure prostaglandin El ranged from 2 to 20 pg and was 4, 1993, accepted (with revisions): February Keywords: priapism; prolonged erection; terbutaline and pulse rate Submitted:]anuary were monitored during this period. selected in an effort to avoid prolonged erections. 15.1993! 1 step is corporal aspiration/irrigation! 24-36% will resolve with aspiration alone! 43-81% resolve with aspiration + sympathomimetic injection (several case series)! Should be attempted before performing shunting procedures Introduction Correspondence: S Priyadarshi Asst. Professor, Department of Urology, SMS Medical College & Hospital, C-80, Gole market, Jawahar Nagar, Jaipur 302004, India. E-mail: dr_shivam@hotmail.com Received 15 December 2002; revised 3 September 2003; accepted 5 November 2003 Results UROLOGY / JULY1993 I VOLUME 42, NUMBER1 51 Materials and methods! Phenlyephrine is recommended (AUA consensus panel) There has been a resurgence of interest in the field of impotence among both patients and physicians with the development of various surgical and nonsurgical therapies. Various vasoactive compounds as intracorporeal injections have been used in both the diagnostic evaluation and treatment of impotence.1 Pharmacologically induced erections have various potential complications of which the most significant is prolonged erection or priapism.2 The incidence of prolonged erection ranges from 2 to 18% depending upon the type of agent and the amount of dose used.2 The standard therapy for such prolonged erection is drainage and irrigation of the corporal bodies with sympathomimetic agents.3 There is no established oral medication although some recent reports have suggested that pseudoephedrine and terbutaline may be effective in reversing such erections.4,5 This study was conducted to Of the 500 impotent patients receiving the intracorporeal injections, 68 (13. 6%) developed prolonged During the last 3 y, 500 men with erectile dysfunction received intracorporeal injection of a bimix solution containing papaverine and chlorpromazine, as part of their evaluation and treatment. The dosage ranged from 0.1 to 0.5 ml. Patients were completely evaluated to make a diagnosis regarding the aetiology of erectile dysfunction. It included history, physical examination, urine analysis, serum testosterone, prolactin blood biochemistry, pharmacologic erection test and penile duplex ultrasonography with pharmacologic stimulation in select patients. All patients were observed in the office until full detumescence occurred. Those patients with full erection persisting for more than 212 h were then treated with oral medication, either terbutaline 5 mg or placebo (sodium bicarbonate) and observed for 15 min. An additional dosage of 5 mg was given if detumescence did not occur after 15 min and 9'

Phenylephrine injection/ aspiration! 100 mcg/ml conc.! Inject 1-2 ml q 3-5 min 100 cc minibag! Up to 1 hr before declaring treatment failure (unlikely to work if priapism > 48-72 hrs)! Aspirate between each injection, pinching base of penis! Only one side necessary A B 10'

Surgical Shunts! Shunts divided anatomically! Distal (Winter, Ebbehoj, T-shunts)! Open distal (Al-Ghorab, Corporal snake)! Proximal (Quackles, Sacher)! Saphenous vein (Grayhack)! Deep dorsal vein shunt! Goal of shunting to reoxygenate cavernous smooth muscle, create fistula between CC and (CS, glans, veins) Percutaneous distal shunts- Winter Shunt ~66% resolution rate Can be performed in ER, in theory 11'

Percutaneous distal shunts- Ebbehoj Shunt! Transglanular! Passed several times through glans to CC 11 Blade! Blood is milked out of penis! Uni- vs. Bi-lateral ~73% resolution rate C T-Shunt Vertical incision 4mm lateral to meatus Through glans to CC Turn 90 away from urethra, remove Milk out blood Surgery Illustrated Surgical Atlas T-shunt with or without tunnelling for prolonged ischaemic priapism 2008 BJU INTERNATIONAL 102, 1754 1764 Maurice M. Garcia, Alan W. Shindel and Tom F. Lue Department of Urology, University of California, San Francisco 12'

Percutaneous distal shunts- T Shunt! Bilateral if persists or returns after 15 min! +/- corporal dilatation (esp if > 36 hours)! Close with absorbable suture! 13/13 with resolution (mean post-op SHIM 18.9) T-Shaped Shunt and Intracavernous Tunneling for Prolonged Ischemic Priapism 0022-5347/09/1814-1699/0 THE JOURNAL OF UROLOGY Vol. 181, 1699-1705, April 2009 Copyright 2009 by A U A Printed in U.S.A. William O. Brant,*, Maurice M. Garcia, Anthony J. Bella, Tom Chi and Tom F. Lue Open Distal Shunts- Al Ghorab Shunt! Grasp w Kocher or 2-0, excise 5x5mm of tunica! Compress/milk out blood! Foley, close ~74% resolution rate 13'

Open Distal Shunts- Corporal Snake Maneuver! Modified Al-Ghorab Shunt! Insert 7/8 Hegar dilator several cm! Named after plumber s snake! ED likely (though natural hx is likely that of ED) Corporal Snake Maneuver 1173! 3/3 resolution! 1/3 erectile function recovery (partial 1/3) 2cm Transverse Incision Corporal Snake Maneuver: Corporoglanular Shunt Surgica Modification for Ischemic Priapism J Sex Med 2009;6:1171 1176 Arthur L. Burnett, MD, and Phillip M. Pierorazio, MD Open Distal Shunts- Corporal Snake Maneuver! Long-term follow-up (7 mo.)! Successful in 8/10 pts (2 had IPP)! Partial erectile function in 2/8! 2/10 had complication Corporal Burnett Snake Surgical Maneuver for the Treatment of Ischemic Priapism: Long-Term Followup THE JOURNAL OF UROLOGY Robert L. Segal,* Nathaniel Readal, Phillip M. Pierorazio, 2013 Arthur by L. A Burnett U A and Trinity J. Bivalacqua Vol. 189, 1025-1029, March 2013 Printed in U.S.A. 14'

Back to Case 1! Aspiration + phenylephrine injection unsuccessful after 1 hour, Winter shunt unsuccessful in ER! Bilateral Ebbhoj, and T shunts unsuccessful in OR, erection returned within 10 minutes. We re going proximal boys!!! Proximal Shunts- Quackles Shunt! CC CS communication! Higher rates of ED with proximal shunts (selection?)! No data to compare univs. bilateral! If bilateral = Sachel! Bilateral should be 1cm apart 15'

Saphenous Vein Shunt- Grayhack! Wedge of tunica excised! Vein anastomosed end to side to CC! No comparative trials on vein shunting! High rates of thrombosis and PE! 10-69% rates of erectile function recovery for vascular shunts. Deep Dorsal Vein Shunt- Clinical Experience and Sexual Function Outcome of Patients With Priapism Treated With Penile Cavernosal-Dorsal Vein Shunt Using Saphenous Vein Graft Rei K. Chiou, Himanshu Aggarwal, Adam C. Mues, Christopher R. Chiou, and Fleur L. Broughton UROLOGY 73 (3), 2009 9/13 had erectile recovery 6/9 enough for sexual activity 16'

! Irreversible Immediate insertion of inflatable penile prosthesis! Avoids difficulty of inserting prosthesis into shortened/fibrotic penis! High risk of erosion if tx w corporal dilation! 5 patients, failed shunting (3-20d)- all satisfied, engaging in sexual intercourse, no complications! Timing a challenge! Min >48 hrs, up to 3 weeks ORIGINAL ARTICLE Early insertion of inflatable prosthesis for intractable ischemic priapism: our experience and review of the literature International Journal of Impotence Research (2011) 23, 158 164 & 2011 Macmillan Publishers Limited All rights reserved 0955-9930/11 O Sedigh 1, L Rolle 1, CLA Negro 1, C Ceruti 1, M Timpano 1, E Galletto 1, K Soltanzadeh 2, H Ajamy 2, J Hosseinee 2, A Al Ansari 3, A Shamsodini 3 and D Fontana 1 The Immediate Insertion of a Penile Prosthesis for Acute Ischaemic Priapism EUROPEAN UROLOGY 56 (2009) 1033 1038 David J. Ralph a, *, Giulio Garaffa a, Asif Muneer a, Alex Freeman b, Rowland Rees a, Andrew N. Christopher a, Sukbinder Minhas a! 50 pts w refractory ischemic priapism! 43 received malleable prosthesis! 7 received IPP (w less edema)! Duration 24-720h (mean 209h)! 96% fully satisfied! Revision rate 24% Type of procedure No. of patients Removal of prosthesis for infection 3 Elective exchange to a three-piece device 6 Revision for erosion 3 Cylinders too short 2 Autoinflation 1 17'

Case 1! Patient achieved detumescence with Quackles shunt! Partial recovery of erectile function! D/C home after 24h of sustained flaccidity Ischemic Priapism- Outcomes! The longer the episode, the less likely for preservation of erectile function! Pryor (1982)- > 24h = > 90% ED rate! Kulmala (1996)- < 24h = 92% erectile function! Bennett and Mulhall (2008)- 39 pts treated for ischemic priapism! 100% had spontaneous erections if < 12h! 78% if between 12-24h! 44% between 24-36h! 0% if > 36h 18'

Research/Future therapies! Evidence that priapism involves dysregulated PDE5 expression! Alterations in NO/cGMP cascade lead to relaxed penile vascular bed via downregulation of PDE5 activity and predispose to priapism! Long-term PDE5i may restore enzymatic activity and reset penis to homeostatic level in those at high risk.! Has shown promise in animal models Research/Future therapies! Pro-fibrotic cytokine TGF- responsible for progressive fibrosis of priapism.! TGF- neutralizing abs decreased fibrosis in rat model! ICI with TGF- neutralizing abs in early phase (<6 hrs) may limit fibrosis. TGF-b 1 neutralizing antibodies decrease the fibrotic effects of ischemic priapism International Journal of Impotence Research (2004) 16, 492 497 O Sanli 1, A Armagan 1, E Kandirali 1, B Ozerman 2, I Ahmedov 1, S Solakoglu 1, A Nurten 2, M Tunç 1, V Uysal 1 and A Kadioglu 1 * 19'

Ischemic Priapism- Questions?! 32 yo M Case 2- He s back! 6 previous ED visits low-flow priapism! Always responded to irrigation/phenylephrine.! Denies drug use, no medications, negative hematologic work-up, no history of trauma.! Diagnosed with recurrent idiopathic ischemic priapism. 20'

Case 2! Presents with 5 hour history of painless erection.! Corporal bodies tumescent, but not fully erect! High-flow priapism suspected.! How many of past visits were high flow? High-Flow Priapism! Persistent erection due to unregulated cavernosal arterial inflow.! Typically corpora tumescent but not rigid.! Usually not painful.! Rare compared to LFP! Natural history is resolution (vs. ED) 21'

Etiology! Straddle injury! Coital trauma! Blunt trauma to penis/perineum! Pelvic fracture! Needle laceration! Vascular erosions (malignant)! Post procedure (DVIU, Nesbit) Pathophysiology High Flow Priapism! Trauma/Injury leads to disruption of cavernous arterial anatomy.! Creates arteriolar-sinusoidal fistula/shunt and increased flow into cavernosa.! Veno-occlusive mechanism intact- Cavernous environment does not become ischemic.! Once correctly diagnosed, does not require emergent intervention.! 62% resolve with conservative tx (ice, compression), no studies comparing vs angiography 22'

Case 2- Colour Doppler Ultrasound Demonstrated increased venous flow to the distal/ proximal penis, and increased arterial flow in left corporal body A Angiography Angiography of left pudendal artery demonstrating fistula between pudendal artery and cavernosa. Patient under went angio-embolization of left penile artery with autologous blood and gel foam with complete resolution and normal erectile function with 2 years follow up 23'

Treatment of High-Flow Priapism! Expectant management (+/- ice, compresses)! Androgen blockade (Lue, 2010)! 7/7 treated for 2-6 months leuprolide! Angiography/Embolization- preservation of erectile function in 75-86%! More on this by Dr. MacHan! Surgical ligation of fistula Radiology and Priapism! Thank you to Dr. MacHan for speaking about the radiologic aspects in diagnosis and treatment of priapism. 24'

Embolization For High Flow Priapism T h e i m a!! Lindsay!Machan,!MD! University!of!British!Columbia!!Vancouver,!British!Columbia!!! Post injury High Flow Priapism Straddle injury Sexual misadventure Rupture of a cavernosal artery with unregulated flow into the lacunar spaces Painless Distension cavernous bodies Corpus spongiosum flaccid 25'

32 yr old carpenter partial erection x 6 weeks Gelfoam embolization 3 months normal erectile function 36 yr old laborer pipe factory partial erection x 3 ½ weeks Steep RAO Embo until flaccid 3 months pharmacologic assisted erections 26'

33 yr old university professor cycling injury A 33 yr old university professor cycling injury Gelfoam embo Minimal recovery of erectile function @ 3 mo 27'

33 yr old university professor cycling injury 46 yr old ski instructor Straddle injury Embolization with autologous blood clot 28'

UBC Experience 14 patients 21 53 years 2 days to 3 months post injury Autologous clot 4 Gelfoam 5 Microcoils + gelfoam 5 Detumescence - 9 / 10 recorded UBC Experience 14 patients 21 53 years 2 days to 3 months post injury FU on 8 patients Spontaneous erections 4 Pharmacologically assisted 3 No erections - 1 29'

Embolic agents reported for high flow priapism autologous clots Gelfoam N-butyl-cyanoacrylate Microcoils Recurrence of priapism 30 40% within 1 month* Urology 2002;59:110 3 Priapism - treatment by embolization - Bastuba et al* 7 patients 4-126 days 7 / 7 successfully embolized 6 / 7 regained full erectile function 2 weeks to 5 months *JUrol 1994, 151:11231-1237 30'

5 year follow up embolization for priapism 9 embolizations in 6 patients traumatic 5 idiopathic 1 Gelfoam - 9 arteries Gelfoam and microcoils 1 Microcoils alone 1 Baba et al Acta Radiol 2007 5 year follow up embolization for priapism No complications recorded 6 / 6 detumescence normal erectile function Baba et al Acta Radiol 2007 31'

Conclusion Embolization for high flow priapism Embolize until detumescence Temporary agents preferable Return of erectile function possible?related to delay of Rx from injury 32'