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Tetsuya Takao md, phd, Department of Urology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan. Email: firstname.lastname@example.org
Abstract: We report a case of high-flow priapism treated successfully with superselective embolization of the cavernous artery. An 18-year-old man presented to our hospital 12 days after having been struck in the perineum by the corner of a skateboard. Immediately after the injury, he suffered painless sustained incomplete erection. High-flow priapism was diagnosed on the basis of cavernosal blood gas analysis and color Doppler ultrasonography findings. Right internal pudendal arteriography showed blood pooling in the cavernosum as a result of a broken artery. We identified the precise position of the arterial–venous fistula and embolized it superselectively with gelatin sponge particles. The fistula disappeared completely. One year later, the patient’s erectile function was completely restored, and there had been no recurrence of the priapism. According to the American Urological Association guidelines, conservative treatment should be attempted first for high-flow priapism. In our review of the literature, superselective arterial embolization could be an alternative treatment after more than 3 weeks of conservative treatment.
High-flow priapism resulting from uncontrolled arterial inflow into the cavernosum describes a persistent erection lasting more than 4 h that is not induced by sexual stimulation. Here, we report a case of high-flow priapism caused by perineal trauma that was treated successfully with superselective embolization of the cavernous artery. In addition, we discuss the criteria for embolization treatment of high-flow priapism in light of a review of the literature.
An 18-year-old man presented to our hospital 12 days after having been struck in the perineum by the corner of a skateboard. Immediately after the injury, the patient suffered painless sustained incomplete erection. We observed a small perineal hematoma, but there was no hematuria or voiding dysfunction. Cavernosal blood gas analysis yielded a Po2 of 97.9 mmHg, a Pco2 of 58.1 mmHg and a pH of 7.463, indicating arterial blood. Color Doppler ultrasound showed a mixed flow pattern of arterial and venous blood in the cavernosum (Fig. 1). High-flow priapism resulting from injury to the cavernosum artery was diagnosed. At the patient’s request, non-invasive perineal compression was attempted first. However, the effect was transient. Twenty days after the injury we decided to carry out transcatheter arterial embolization. A 4 Fr angiographic catheter was inserted via the right femoral artery and pelvic angiography revealed blood pooling in the right side of the penis. Right internal pudendal arteriography (Fig. 2a,b) confirmed an arterial–venous fistula resulting from the injury to the cavernosal artery. A 2.0 Fr microcatheter (Progreat α, Terumo, Tokyo, Japan) was superselectively advanced as close as possible to the fistula, and embolization was carried out using gelatin sponge particles (Spongel, Yamanouchi Pharmaceutical Company, Tokyo, Japan). The fistula disappeared completely (Fig. 3). The patient’s erectile function was not fully normal 1 month after embolization; however, 1 year after embolization erectile function was completely restored and there has been no recurrence of the priapism.
Priapism is defined as a persistent erection that is not induced by sexual stimulation and that lasts for more than 4 h (American Urological Association [AUA] guidelines; http://www.auanet.org/guidelines/priapism.cfm). The AUA guidelines include a management algorithm for priapism. In brief, the guidelines recommend ‘observation’ as an initial management of non-ischemic (high-flow) priapism. Immediate invasive interventions (embolization or surgery) are recommended to be carried out at the request of the patient. In response to the patient’s request for treatment, selective arterial embolization is recommended as a second step management. Surgical management is the last option or last resort for long-standing cases. In accordance with this algorithm, we attempted compression at the site of the fistula, which was identified by color Doppler ultrasonography, by instructing the patient in the compression technique. However, color Doppler ultrasonography showed that the effect was transient. Therefore, we embolized the internal pudendal artery.
According to the AUA guideline, conservative treatment should be attempted first in cases of non-ischemic priapism. Only after failure of conservative treatment should arteriography and embolization be carried out. Several reported cases of high-flow priapism did not involve pain and improved spontaneously without treatment. In one rare case, a patient suffered arterial priapism for 31 years without any subsequent erectile dysfunction (ED),1 which indicated that no treatment was needed. Indeed, in studies of children, three of four cases2 and one of two cases3 of priapism resolved spontaneously without any treatment. In adult patients, only one of three cases continued for more than 43 months under a conservative strategy.4 The other two patients eventually opted to undergo embolization therapy. Although non-ischemic priapism can resolve without treatment, investigators have discussed the disadvantages of a watchful waiting strategy, including the theoretical considerations of possible structural alterations resulting from excessive arterial inflow as well as social and psychological difficulties related to the condition.4 However, spontaneous detumescence of non-ischemic priapism and preservation of erectile function cannot be relied on to occur. Tambo et al.5 reviewed 64 cases of high-flow priapism in the literature and reported that in two of seven cases (71%) erectile function did not improve after conservative follow up. Because O2 saturation in the cavernous bodies is elevated to arterial levels in such cases, there is no risk of ischemic damage to the tissue, but long-term change, such as intracavernous pseudoaneurysm with secondary fibrosis, may lead to impaired erectile function,6 indicating the possibility of ED after long-term conservative treatment.
In the AUA guidelines, the duration of conservative treatment has not been described. The guidelines state that immediate invasive interventions can be carried out at the request of the patient. Thus, it is uncertain when conservative treatment should be terminated and the next step in the treatment algorithm carried out. One report mentioned that even for small fistulas, any possible spontaneous closure usually occurs within approximately 3 weeks.2 In successful cases treated conservatively, the symptoms improved gradually within 3 weeks. Thus, if priapism does not resolve after 3 weeks, highly selective embolization might be considered.7 It appears to be difficult for a fistula with a clot to close spontaneously after 3 weeks.
One reason to choose conservative treatment first is the supposed risk of ED after embolization. Whether embolization is actually associated with a risk of ED is not clear. To our knowledge, few reports discuss the risk of ED after embolization. Savoca et al.7 reported that patients who were treated early with embolization, most of whom were trauma patients, did not have fibrosis or changes in erectile function at the long-term follow-up examination. Transient ED occurs shortly after embolization in some cases. With short-term follow-up, it is difficult to determine the degree of ED because it may gradually improve after embolization. The time needed to improve erectile function in reported cases ranges from 7 days to 1 year.5 Moreover, even in cases of ED following embolization, it is unclear whether ED was caused by the embolization, prolonged priapism or perineal trauma or by pretreatment such as conservative therapy or an arterial–venous shunt. With recent advances in interventional radiological techniques, superselective embolization using absorbable material is less invasive. Even if the conservative treatment was first selected according to the AUA guidelines, in our review of the literature, superselective arterial embolization should be considered positively after 3 weeks of conservative treatment. Future study is needed to determine the best management algorithm for high-flow priapism.