Case Report

International Journal of Impotence Research (2005) 17, 304–306. doi:10.1038/sj.ijir.3901251 Published online 3 February 2005

High-flow priapism (HFP) secondary to Nesbit operation: management by percutaneous embolization and colour Doppler-guided compression

G Liguori1, G Garaffa1, C Trombetta1, M Capone2, M Bertolotto3, F Pozzi-Mucelli3 and E Belgrano1

  1. 1Department of Urology, University of Trieste, Trieste, Italy
  2. 2Division of Urology, General Hospital, Gorizia, Trieste, Italy
  3. 3Department of Radiology, University of Trieste, Trieste, Italy

Correspondence: G Liguori, MD, Via Sticotti n2, 34123-Trieste, Italy. E-mail: gioliguori@libero.it

Received 12 December 2003; Revised 2 April 2004; Accepted 20 May 2004; Published online 3 February 2005.

Keywords:

penis, high flow priapism, embolization, ultrasound

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Introduction

High-flow priapism (HFP) is an uncommon clinical entity that is typically associated with perineal or penile trauma with laceration of the cavernous artery, leading to arterial–lacunar fistula,1 and is characterized by a persistent, partial and not painful erection.2 History and physical examination followed by corporeal blood gas analysis and colour Doppler ultrasound (CDU) or selective internal pudendal arteriography usually lead to the diagnosis.3 The management of HFP is still controversial and typically includes selective internal pudendal embolization or open surgical legation of the arterial–lacunar fistula; conservative options, such as drainage of the corpora cavernosa with needle aspiration and intracavernous injections of alpha-adrenergic agonists, have been used with only temporary results.4

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Case report

A 20-y-old man who underwent Nesbit corporoplasty in another department sought medical attention at a community hospital for having noticed the development of persistent penile erection approximately 12 h after surgery. Drainage of the corpora cavernosa with needle aspiration and several irrigations with 10 mg/ml phenylephrine produced only a transient detumescence and therefore he was sent to our department.

Penile blood gas analysis revealed a pH of 7.35, PO2 of 93 mm Hg and PCO2 of 36 mmHg. CDU revealed a turbulent blood flow from a branch of the right cavernous artery to the lacunar spaces and the formation of an arterial–lacunar fistula between the proximal and distal part of the penis (Figure 1). The fistula was localized in the point of insertion of the needle used to obtain the hydraulic erection during Nesbit operation.

Figure 1.
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Colour Doppler ultrasound demonstrates the presence of turbulent arterial flow surrounding the cavernosal artery.

Full figure and legend (58K)

Selective arteriography of the right pudendal artery was subsequently performed confirming the presence of the lesion and therefore a supraselective catheterization of the lacerated artery with embolization of the fistula by injecting autologous blood clots was then attempted (Figure 2a, b). This manoeuvre determined only a partial detumescence of the corpora cavernosa.

Figure 2.
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(a) Location of arterial vascular fistula between the proximal and distal part of the penis in the point of insertion of the needle used to obtain the hydraulic erection is confirmed by the characteristic blush of contrast material extravasated from lacerated cavernous artery. (b) Absence of flow is documented arteriographically after therapeutic embolization with autologous clot.

Full figure and legend (68K)

CDU was performed 24 h after this procedure and demonstrated partial flow persistence at the distal part of the arterial–lacunar fistula (Figure 3a, b). Therefore, in order to achieve vasospasm with complete thrombosis, CDU-guided perineal compression with ice was performed applying downward pressure for 60 min against the pubic bone (Figure 4).

Figure 3.
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(a) Colour Doppler ultrasound showing a high-velocity flow through an arteriocavernosal fistula into the cavernosal body. (b) Spectral analysis shows the typical waveform pattern of an arteriosinusoidal fistula.

Full figure and legend (143K)

Figure 4.
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Colour Doppler ultrasound control after embolization; no pathologic arterial flow towards the cavernous bodies is detected.

Full figure and legend (61K)

According to the protocol of our department, postoperative evaluation includes CDU at 1 day, 1 month and 6 months after the procedure and sexual function investigation using the International Index of Erectile Function (IIEF).3 CDU performed the day after the perineal compression demonstrated the complete obliteration of the fistula by documenting its complete isoechogenicity; this evidence has been further confirmed by the ECD performed after 1 and 6 months. IIEF was administered 6 months after the procedure and demonstrated that the patient had sufficient penile rigidity for intercourse.

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Comments

Priapism, defined as a persistent penile erection not associated with sexual desire, may be classified into low- and high-flow states. Low-flow priapism (LFP), the most common one, is secondary to inadequate venous outflow caused by obstruction of subtunical venules leading to hypoxia, acidosis and consequently fibrosis of the corpora cavernosa and is characterized by a prolonged and painful erection.5 On the contrary, HFP is an uncommon clinical entity and is usually associated with penile or perineal blunt trauma leading to high arterial blood flow into lacunar spaces by a fistula, by-passing high-resistance elicine arteries. Blood remains oxygenated and permanent fibrosis and cellular damage are therefore rare.6

Diagnosis is typically based on penile blood gas determination and on CDU ultrasound documentation of the arterial–sinusoidal fistula.7 In our patient, blood gas analysis revealed high oxygen tension and CDU clearly demonstrated a turbulent blood flow surrounding a branch of the cavernosal artery as clear evidence of its injury.

Our case is paradigmatic because it demonstrates that needle insertion in the penis shaft can lead to injury of the cavernous artery or of its branches and to HFP. Therefore, in order to reduce the risk of this event, if hydraulic erection is required, the needle must be inserted in the corpora cavernosa distally, through the glans.

The main aim of management of HFP is to reverse priapism by temporarily occluding the cavernosal artery, allowing the laceration to heal and, at a later date, restoring cavernosal artery flow with preservation of erectile function.8 Therefore, percutaneous embolization by absorbable material such as autologous blood clot, microcoils or gelatin sponge must be considered the treatment of choice in patients with HFP since it ensures a transitory interruption of arterial flow through the lacerated vessels and the subsequent dissolution of the embolic substance allows the re-establishment of the arterial flow.9 Complications of this procedure are rare and include penile gangrene, persistent impotence, gluteal ischaemia, purulent cavernositis and perineal abscess.10

However, according to our experience, in approximately 30% of cases, fistula recurrence develops; this event is suggested by physical examination that shows the presence of priapism symptoms, and is confirmed by CDU.

Our case demonstrates that, in case of persistence, CDU-guided selective compression may represent an important tool to obtain its complete resolution. In case of failure, a second pelvic angiography with selective iterative embolization is required and this procedure almost always proves conclusive.11

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References

  1. Hatzichristou D et al.. Management strategy for arterial priapism: therapeutic dilemmas. J Urol 2002; 168: 2074−2077. | Article | PubMed |
  2. Ankem MK et al.. High-flow priapism: a novel way of lateralising the lesion in radiologically inapparent cases. Urology 2001; 57: 800iv−800vi. | Article |
  3. Ciampalini S et al.. High-flow priapism: treatment and long term follow-up. Urology 2002; 59: 110−113. | Article | PubMed | ISI |
  4. Mizutani M et al.. Treatment of post-traumatic priapism by intracavernous injection of alpha stimulants. Urol Int 1986; 41: 312−314. | PubMed | ChemPort |
  5. Hauri D, Spycher M & Bauman W. Erection and priapism: a new physiopathological concept. Urol Int 1983; 38: 138−145. | PubMed | ChemPort |
  6. Park JK, Jeong YB & Han YM. Recanalization of embolized cavernosal artery: restoring potency in the patient with high flow priapism. J Urol 2002; 165: 2002−2003.
  7. Feldstein VA. Post-traumatic 'high-flow' priapism evaluation with color flow Doppler sonography. J Ultrasound Med 1993; 12: 589−593. | PubMed | ChemPort |
  8. Hakim L et al.. Evolving concepts in the diagnosis and treatment of arterial high flow priapism. J Urol 1996; 155: 541−548. | Article | PubMed | ChemPort |
  9. Walker TJ et al.. 'High-flow' priapism: treatment with superselective transcatheter embolization. Radiology 1990; 174: 1053−1054. | PubMed | ChemPort |
  10. Sandock DS et al.. Perineal abscess after embolization for high-flow priapism. Urology 1996; 48: 308−311. | Article | PubMed | ChemPort |
  11. Mabjeesh N, Shemesh D & Abramowitz HB. Post-traumatic high flow priapism: successful management using duplex guided compression. J Urol 1999; 161: 215−216. | Article | PubMed | ChemPort |
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