Priapism: Difference between revisions

Line 20:

*# '''Fully rigid and tender corpora cavernosa'''

*# '''Abnormal blood gas (i.e., hypoxic, hypercarbic, acidotic)'''

* '''Requires prompt evaluation and may require emergency management'''

*#'''Requires prompt evaluation and may require emergency management'''

** Natural history of untreated acute ischemic priapism includes days to weeks of painful erections followed by permanent loss of erectile function

*#'''Non-traumatic etiology'''

**'''Duration of ischemic priapism is associated with the risk of future erectile dysfunction'''

* Natural history of untreated acute ischemic priapism includes days to weeks of painful erections followed by permanent loss of erectile function

*** In sickle cell disease patients in whom priapism was reversed, spontaneous erections (with or without use of sildenafil) were reported in:

*'''Duration of ischemic priapism is associated with the risk of future erectile dysfunction'''

**** '''100% when priapism was reversed by 12 hours'''

** In sickle cell disease patients in whom priapism was reversed, spontaneous erections (with or without use of sildenafil) were reported in:

**** ≈'''75% when reversed by 12-24 hours'''

*** '''100% when priapism was reversed by 12 hours'''

**** '''≈50% when reversed by 24-36 hours'''

*** ≈'''75% when reversed by 12-24 hours'''

**** '''0% when reversed ≥36 hours'''

*** '''≈50% when reversed by 24-36 hours'''

****[https://pubmed.ncbi.nlm.nih.gov/18312286/ Bennett, Nelson, and John Mulhall. "Sickle cell disease status and outcomes of African-American men presenting with priapism." ''The journal of sexual medicine'' 5.5 (2008): 1244-1250.]

*** '''0% when reversed ≥36 hours'''

*** '''A more recent study that the cutoff for irreversible restoration of erectile tissue is 48 hours[https://pubmed.ncbi.nlm.nih.gov/23892191/]'''

***[https://pubmed.ncbi.nlm.nih.gov/18312286/ Bennett, Nelson, and John Mulhall. "Sickle cell disease status and outcomes of African-American men presenting with priapism." ''The journal of sexual medicine'' 5.5 (2008): 1244-1250.]

*** '''Interventions beyond 48-72 hours of onset may relieve erection and pain but have little benefit in preserving potency'''

** '''A more recent study suggested that the cutoff for irreversible restoration of erectile tissue is 48 hours[https://pubmed.ncbi.nlm.nih.gov/23892191/]'''

** '''Interventions beyond 48-72 hours of onset may relieve erection and pain but have little benefit in preserving potency'''

=== Non-ischemic priapism (arterial, high-flow) ===

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*'''Pathogenesis:'''

** Likely results from unregulated control of arterial inflow and cavernous smooth muscle tone

**'''Usually involves perineal or penile trauma''' resulting in laceration of the cavernous artery (or one of its branches within the corpora) '''and unregulated cavernous arterial inflow. ~~The arteriolacunar fistula is typically unilateral~~'''.

**'''Usually involves perineal or penile trauma''' '''resulting in laceration of the cavernous artery (or one of its branches within the corpora)''' '''and unregulated cavernous arterial inflow.'''

*** '''Most common cause is a straddle injury''' to the crura

**** '''Other mechanisms of traumatic arterial laceration include''' coital trauma, kicks to the penis or perineum, pelvic fractures, birth canal trauma to the male newborn, needle lacerations, iatrogenic needle injury, complications of penile diagnostics, vascular erosions complicating metastatic infiltration of the corpora, and after iatrogenic trauma from coldknife urethrotomy, corporoplasty, and penile revascularization procedures

***** '''Sustained partial erection may develop 24 hours after perineal or penile blunt trauma'''

***** '''After either aggressive medical management of ischemic priapism or surgical shunting, priapism may rapidly recur with conversion from ischemic (low-flow) to non-ischemic (high-flow)'''

***'''The arteriolacunar fistula is typically unilateral'''.

** '''After either aggressive medical management of ischemic priapism or surgical shunting, priapism may rapidly recur with conversion from ischemic (low-flow) to non-ischemic (high-flow)'''

** '''Other causes include Fabry disease and sickle cell anemia'''

* '''Associated with''' (features that distinguish this from ischemic priapism)

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*#* '''Patients do report additional engorgement with sexual stimulation, with return to partial erection after climax'''

*# '''Normal penile blood gas''' (features that distinguish this from non-ischemic priapism)

* '''Once properly diagnosed, does not require emergent intervention'''

*#'''Once properly diagnosed, does not require emergent intervention'''

*#'''Traumatic etiology, usually'''

=== Recurrent ischemic priapism ===

* '''Definition: Recurrent ischemic episodes, with or without meeting the 4-hour time criteria for priapism'''

* Also known as "stuttering" priapism

*'''Definition: Recurrent ischemic episodes, with or without meeting the 4-hour time criteria for priapism'''

**Unwanted painful erections occur repeatedly with intervening periods of detumescence

**The key differentiating factor between the current definition of recurrent ischemic priapism and other recurrent priapism-like conditions is the requirement of confirmed penile ischemia.

***Priapism-like conditions include sleep-related painful erections, undesired prolonged erections, and recurrent non-ischemic priapism

**'''Both acute ischemic priapism and non-ischemic priapism may recur over time'''

*'''Both acute ischemic priapism and non-ischemic priapism may recur over time'''

*Commonly known as "stuttering" priapism

*'''Commonly associated with sickle cell disease'''

** '''Priapism in children and adolescents is most commonly related to sickle cell disease'''

*** The sickle cell genetic mutation is the result of a single amino acid substitution in the beta-globin subunit of hemoglobin S.

*** Clinical features seen in homozygous sickle cell disease: chronic hemolysis, vascular occlusion, tissue ischemia, and end-organ damage.

*** Sickle cell trait can be a predisposing factor to ischemic priapism.

*** '''Sickle cell trait can be a predisposing factor to ischemic priapism.'''

** Pathogenesis is related to hemolysis and reduced nitric oxide

* '''Management focuses on ~~treatment~~ of acute episodes ~~and prevention~~ of future events.'''

* '''Management focuses on'''

**'''Treatment of acute episodes'''

**'''Prevention of future events'''

*

@@ Line 20: / Line 20: @@
 *# '''<span style="color:#ff0000">Fully rigid and tender corpora cavernosa</span>'''
 *# '''<span style="color:#ff0000">Abnormal blood gas</span> (i.e., hypoxic, hypercarbic, acidotic)'''
-* '''<span style="color:#ff0000">Requires prompt evaluation and may require emergency management</span>'''
+*#'''<span style="color:#ff0000">Requires prompt evaluation and may require emergency management</span>'''
-** Natural history of untreated acute ischemic priapism includes days to weeks of painful erections followed by permanent loss of erectile function
+*#'''<span style="color:#ff0000">Non-traumatic etiology</span>'''
-**'''<span style="color:#ff0000">Duration of ischemic priapism is associated with the risk of future erectile dysfunction</span>'''
+* Natural history of untreated acute ischemic priapism includes days to weeks of painful erections followed by permanent loss of erectile function
-*** In sickle cell disease patients in whom priapism was reversed, spontaneous erections (with or without use of sildenafil) were reported in:
+*'''<span style="color:#ff0000">Duration of ischemic priapism is associated with the risk of future erectile dysfunction</span>'''
-**** '''100% when priapism was reversed by 12 hours'''
+** In sickle cell disease patients in whom priapism was reversed, spontaneous erections (with or without use of sildenafil) were reported in:
-**** ≈'''75% when reversed by 12-24 hours'''
+*** '''100% when priapism was reversed by 12 hours'''
-**** '''≈50% when reversed by 24-36 hours'''
+*** ≈'''75% when reversed by 12-24 hours'''
-**** '''0% when reversed ≥36 hours'''
+*** '''≈50% when reversed by 24-36 hours'''
-****[https://pubmed.ncbi.nlm.nih.gov/18312286/ Bennett, Nelson, and John Mulhall. "Sickle cell disease status and outcomes of African-American men presenting with priapism." ''The journal of sexual medicine'' 5.5 (2008): 1244-1250.]
+*** '''0% when reversed ≥36 hours'''
-*** '''A more recent study that the cutoff for irreversible restoration of erectile tissue is 48 hours[https://pubmed.ncbi.nlm.nih.gov/23892191/]'''
+***[https://pubmed.ncbi.nlm.nih.gov/18312286/ Bennett, Nelson, and John Mulhall. "Sickle cell disease status and outcomes of African-American men presenting with priapism." ''The journal of sexual medicine'' 5.5 (2008): 1244-1250.]
-*** '''<span style="color:#ff0000">Interventions beyond 48-72 hours of onset may relieve erection and pain but have little benefit in preserving potency</span>'''
+** '''A more recent study suggested that the cutoff for irreversible restoration of erectile tissue is 48 hours[https://pubmed.ncbi.nlm.nih.gov/23892191/]'''
+** '''<span style="color:#ff0000">Interventions beyond 48-72 hours of onset may relieve erection and pain but have little benefit in preserving potency</span>'''
 === Non-ischemic priapism (arterial, high-flow) ===
@@ Line 37: / Line 38: @@
 *'''<span style="color:#ff0000">Pathogenesis:</span>'''
 ** Likely results from unregulated control of arterial inflow and cavernous smooth muscle tone
-**'''<span style="color:#ff0000">Usually involves perineal or penile trauma</span>''' resulting in laceration of the cavernous artery (or one of its branches within the corpora) '''and unregulated cavernous arterial inflow. The arteriolacunar fistula is typically unilateral'''.
+**'''<span style="color:#ff0000">Usually involves perineal or penile trauma</span>''' '''resulting in laceration of the cavernous artery (or one of its branches within the corpora)''' '''and unregulated cavernous arterial inflow.'''
 *** '''<span style="color:#ff0000">Most common cause is a straddle injury</span>''' to the crura
 **** '''Other mechanisms of traumatic arterial laceration include''' coital trauma, kicks to the penis or perineum, pelvic fractures, birth canal trauma to the male newborn, needle lacerations, iatrogenic needle injury, complications of penile diagnostics, vascular erosions complicating metastatic infiltration of the corpora, and after iatrogenic trauma from coldknife urethrotomy, corporoplasty, and penile revascularization procedures
 ***** '''Sustained partial erection may develop 24 hours after perineal or penile blunt trauma'''
-***** '''<span style="color:#ff0000">After either aggressive medical management of ischemic priapism or surgical shunting, priapism may rapidly recur with conversion from ischemic (low-flow) to non-ischemic (high-flow)'''
+***'''The arteriolacunar fistula is typically unilateral'''.
+** '''<span style="color:#ff0000">After either aggressive medical management of ischemic priapism or surgical shunting, priapism may rapidly recur with conversion from ischemic (low-flow) to non-ischemic (high-flow)'''
 ** '''Other causes include Fabry disease and sickle cell anemia'''
 * '''<span style="color:#ff0000">Associated with</span>''' (features that distinguish this from ischemic priapism)
@@ Line 49: / Line 51: @@
 *#* '''Patients do report additional engorgement with sexual stimulation, with return to partial erection after climax'''
 *# '''<span style="color:#ff0000">Normal penile blood gas</span>''' (features that distinguish this from non-ischemic priapism)
-* '''<span style="color:#ff0000">Once properly diagnosed, does not require emergent intervention</span>'''
+*#'''<span style="color:#ff0000">Once properly diagnosed, does not require emergent intervention</span>'''
+*#'''<span style="color:#ff0000">Traumatic etiology, usually</span>'''
 === Recurrent ischemic priapism ===
-* '''<span style="color:#ff0000">Definition: Recurrent ischemic episodes, with or without meeting the 4-hour time criteria for priapism</span>'''
+* Also known as "stuttering" priapism
+*'''<span style="color:#ff0000">Definition: Recurrent ischemic episodes, with or without meeting the 4-hour time criteria for priapism</span>'''
 **Unwanted painful erections occur repeatedly with intervening periods of detumescence
 **The key differentiating factor between the current definition of recurrent ischemic priapism and other recurrent priapism-like conditions is the requirement of confirmed penile ischemia.
 ***Priapism-like conditions include sleep-related painful erections, undesired prolonged erections, and recurrent non-ischemic priapism
-**'''Both acute ischemic priapism and non-ischemic priapism may recur over time'''
+*'''Both acute ischemic priapism and non-ischemic priapism may recur over time'''
-*Commonly known as "stuttering" priapism
 *'''<span style="color:#ff0000">Commonly associated with sickle cell disease</span>'''
 ** '''<span style="color:#ff0000">Priapism in children and adolescents is most commonly related to sickle cell disease</span>'''
 *** The sickle cell genetic mutation is the result of a single amino acid substitution in the beta-globin subunit of hemoglobin S.
 *** Clinical features seen in homozygous sickle cell disease: chronic hemolysis, vascular occlusion, tissue ischemia, and end-organ damage.
-*** Sickle cell trait can be a predisposing factor to ischemic priapism.
+*** '''Sickle cell trait can be a predisposing factor to ischemic priapism.'''
 ** Pathogenesis is related to hemolysis and reduced nitric oxide
-* '''<span style="color:#ff0000">Management focuses on treatment of acute episodes and prevention of future events.</span>'''
+* '''<span style="color:#ff0000">Management focuses on</span>'''
+**'''<span style="color:#ff0000">Treatment of acute episodes</span>'''
+**'''<span style="color:#ff0000">Prevention of future events</span>'''
 *