MODERN APPROACHES TO THE DIAGNOSIS AND TREATMENT OF NONISCHEMIC (ARTERIAL) PRIAPISM

The article analyzes information on prevalence, etiology, peculiarities of differential diagnosis, as well as indications and methods of surgical treatment of non-ischemic (arterial) priapism. The literature data are supplemented by the results of our own observations.

The disease is characterized by a rarity and significant differences in therapeutic tactics in comparison with ischemic (venous) priapism. Arterial priapism occurs about 50 times less often than venous and in most cases is secondary to trauma of the penis, perineum or congenital abnormalities of the vessels of the penis. Primary, that is, unclear etiology, arterial priapism is described as a casuistic rarity.

Laboratory-confirmed arterial priapism is a planned situation, not requiring immediate measures to stop the pathological erection, while the outcome of venous priapism directly depends on the duration of the disease and the success of emergency urological care.

The main method of differential diagnosis of hemodynamic forms of priapism is the gasometry of blood obtained by puncture of cavernous bodies. The absence of hypoxia is a pathognomonic symptom of arterial priapism and serves as a rationale for angiography, the task of which is the topical diagnosis of vascular disorders.

The revealed pathological vascular joints undergo superselective embolization. The effectiveness of the technique in terms of stopping the pathological erection is close to 100%.

Surgical tactics do not depend on the etiology of arterial priapism: posttraumatic and “non-traumatic” variants of the disease imply an absolutely identical approach.

Expectant  tactics  regarding  arterial  priapism  are  the  subject  of  scientific  discussion.  Despite  the  possibility  of an independent cessation of pathological erection with arterial priapism, due to the risk of developing cavernous fibrosis, expectant management is appropriate only in children with undisputed posttraumatic etiology of the disease. The observation period should not exceed 3–4 weeks.

The prognosis of arterial priapism is much better than venous. Arterial priapism, as well as endovascular methods of its treatment are not accompanied by the risk of acute cavernitis. Erectile function, provided the timeliness of the intervention is preserved in virtually all patients.

1. Berger R, Billups K, Brock G, Broderick GA, Dhabuwala CB, Goldstein I, et al. Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism. Int J Impot Res. 2001 Dec;13 Suppl 5: S39–43. DOI: 10.1038/sj.ijir.3900777

2. Broderick GA, Kadioglu A, Bivalacqua TJ, Ghanem H, Nehra A, Shamloul R. Priapism: pathogenesis, epidemiology, and management. J Sex Med. 2010 Jan;7 (1 Pt 2):476–500. DOI: 10.1111/j.1743–6109.2009.01625.x.

3. Rukovodstvo po andrologii. Ed by Tiktinskii OL. Leningrad: “Meditsina” Publ., 1990, pp. 113–114. (In Russian).

4. Urologiya [Urology]. Ed by Loparkin NA. Мoscow: “GEOTAR-Media” Publ., 2009, 1021 p. (In Russian).

5. Yarovoi SK, Khromov RA, Dzidzariya AG, Prokhorov AV. Voprosy urgentnoi andrologii [Issues of urgent andrology]. Мoscow: “Uromedia” Publ., 2016, 120 p. (In Russian).

6. Shcheplev PA, Gvasaliya BR, Ipatenkov VV. Trauma of the penis as a cause of penile arterial priapism form. Clinical case. Andrology and Genital Surgery. 2014; 1: 76–79. (In Russian).

7. Aphinives C, Laopaiboon V, Chotikawanit A. Postsurgical high flow priapism treated by transarterial embolizaton: a case report. J Med Assoc Thai. 2012 Jan; 95 (1): 129–31.

8. Mire G, Dong XZ, Xin ZC, Dai YT. Spontaneous high flow arterial priapism of old males. Zhonghua Nan Ke Xue. 2003; 9 (4): 299–300, 302.

9. Poey C, Guy F, Rabia N, Vergnolle M, Khadji A, Raynaud M, Dutheil A. Non traumatic high flow priapism: arterial embolization treatment. J Radiol. 2006 Feb; 87 (2 Pt 1): 115–9.

10. Kulmala RV, Lehtonen TA, Lindholm TS. Permanent open shunt as a reason for impotence or reduced potency after surgical treatment of priapism in 26 patients. Int J Impot Res. 1995 Sep; 7 (3): 175–80.

11. Yunda IF. Bolezni muzhskikh polovykh organov [Diseases of male genital organs]. Kiev: “Zdorov’ya” Publ., 1989, 272 p. (In Russian).

12. Takao T, Osuga K, Tsujimura A, Matsumiya K, Nonomura N, Okuyama A. Successful superselective arterial embolization for post-traumatic high-flow priapism. Int J Urol. 2007 Mar; 14 (3): 254–6. DOI: 10.1111/j.1442–2042.2007.01574.x

13. Yarovoi SK, Khromov RA, Shipovskii VN. Arterial priapism as a complication of a stab wound in the perianal area. Urology. 2017; 5: 86–90. DOI: 10.18565/urology.2017.5.86–90 (In Russian).

14. Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, et al. American Urological Association guideline on the management of priapism. J Urol. 2003 Oct; 170 (4 Pt 1): 1318–24. DOI: 10.1097/01.ju.0000087608.07371.ca

15. Maximov VA, Yarovoi SK, Khromov RA, Prokhorov AV, Stranadko MV. Urgent andrological care in Moscow: current status and perspectives of the service. Urology. 2012; 1: 72–76. (In Russian).

16. Bertolotto M, Zappetti R, Pizzolato R, Liguori G. Color Doppler appearance of penile cavernosal-spongiosal communications in patients with high-flow priapism. Acta Radiol. 2008 Jul; 49 (6): 710–4. DOI: 10.1080/02841850802027026.

17. Dabbeche C, Neji H, Haddar S, Daoud E, Ben Mahfoudh K, Mnif J. Post-traumatic priapism successfully managed with selective embolization. Congress: CIRSE 2010. e-Poster: P-100.

18. Kirkham AP, Illing RO, Minhas S, Allen C. MR imaging of nonmalignant penile lesions. Radiographics. Radiographics. 2008 May-Jun; 28 (3): 837–53. DOI: 10.1148/rg.283075100

19. Emir L, Tekgül S, Karabulut A, Oskay K, Erol D. Management of post-traumatic arterial priapism in children: presentation of a case and review of the literature. Int Urol Nephrol. 2002; 34 (2): 237–40.

20. Hanada E, Kageyama S, Narita M, Kim CJ, Yoshiki T, Okada Y, et al. Case report of post-traumatic arterial high-flow priapism. Hinyokika Kiyo. 2008 Sep; 54 (9): 633–5.

21. Corbetta JP, Durán V, Burek C, Sager C, Weller S, Paz E, Lopez JC. High flow priapism: diagnosis and treatment in pediatric population. Pediatr Surg Int. 2011 Nov; 27 (11): 1217–21. DOI: 10.1007/s00383–011–2911–7

22. Moscovici J, Barret E, Galinier P, Liard A, Juricic M, Mitrofanoff P, Juskiewenski S. Post-traumatic arterial priapism in the child: a study of four cases. Eur J Pediatr Surg. 2000 Feb; 10 (1): 72–6. DOI: 10.1055/s-2008–1072329

23. Yesilkaya Y, Peynircioglu B, Gulek B, Topcuoglu M, Inci K. Autologous blood-clot embolisation of cavernosal artery pseudoaneurysm causing delayed high-flow priapism. Pol J Radiol. 2013 Apr; 78 (2): 54–6. DOI: 10.12659/PJR.883946

24. Lloret F, Martínez-Cuesta A, Domínguez P, Noguera JJ, Bilbao JI. Arterial microcoil embolization in high flow priapism. Radiologia. 2008 Mar-Apr; 50 (2): 163–7.

25. Tønseth KA, Egge T, Kolbenstvedt A, Hedlund H. Evaluation of patients after treatment of arterial priapism with selective micro-embolization. Scand J Urol Nephrol. 2006;40 (1):49–52. DOI: 10.1080/00365590500338040

26. Castaño GI, Moncada II, Subirá RD, Moralejo GM, Martínez SJ, Cabello BR, Hernández F. C. Resolution of a case of arterial priapism secondary to bilateral arteriocavernous fistula with selective embolization using reabsorbible material. Actas Urol Esp. 2004 Nov-Dec; 28 (10): 777–80.

27. Carnevale FC, Petterle PH, Sousa Junior WO, Protta T, Oliveira RA, Motta-Leal-Filho JM, et al. Percutaneous treatment of highflow priapism: a case report. Congress: CIRSE 2010. e-Poster: P-96.

28. Yarovoi SK, Khromov RA. Taktika ekstrennoi urologicheskoi pomoshchi pri ishemicheskom priapizme. Lechaschi Vrach Journal. 2014; 1: 46–49. (In Russian).

29. Oztürk MH, Gümüş M, Dönmez H, Peynircioğlu B, Onal B, Dinç H. Materials in embolotherapy of high-flow priapism: results and long-term follow-up. Diagn Interv Radiol. 2009 Sep; 15 (3): 215–20.

30. Baba Y, Hayashi S, Ueno K, Nakajo M. Superselective arterial embolization for patients with high-flow priapism: results of follow-up for five or more years. Acta Radiol. 2007 Apr; 48 (3): 351–4. DOI: 10.1080/02841850701199934

31. Maksimov V, Yarovoy S, Prokhorov A, Misyakova О, Moskaleva N. Emergency urologic care in priapism: results of retrospective analysis. Vrach (The Doctor). 2012; 6: 45–47. (In Russian).