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GENITOURINARY TRACT IMAGING Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 2  |  Page : 257-260
Post-traumatic high-flow priapism treated by transarterial embolisation a case report


Department of Radiology, Amrita Institute of Medical Sciences, Amrita Lane, Elamakkara, Cochin-682026, Kerala, India

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Keywords: Priapism, Colour Doppler, embolisation

How to cite this article:
Prabhu N K, Moorthy S, SreeKumar K P, Pillai A K. Post-traumatic high-flow priapism treated by transarterial embolisation a case report. Indian J Radiol Imaging 2002;12:257-60

How to cite this URL:
Prabhu N K, Moorthy S, SreeKumar K P, Pillai A K. Post-traumatic high-flow priapism treated by transarterial embolisation a case report. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Nov 14];12:257-60. Available from: http://www.ijri.org/text.asp?2002/12/2/257/28459

   Introduction Top


High flow priapism is an uncommon entity, usually secondary to blunt or penetrating trauma to the perineum. Its management differs radically from the low flow (venoocclusive) priapism, hence making the differentiation important. High flow priapism can be elegantly treated by transarterial embolisation, resulting in a cure while avoiding the complications of surgery.


   Case Report Top


A 26-year-old man with an acute straddle injury to the perineum while on a ship had difficulty voiding after the injury and was catheterized. He developed persistent erection after 48 hours. On removal of the urinary catheter 15 days later, urinary stream gradually diminished in caliber and force. On examination, there was sustained erection, turgid corpora with slight swelling and tenderness in the region of the bulbar urethra and anterior perineum. There was no external injury.

A micturating cystourethrogram [Figure - 1] revealed a short segment stricture of the bulbar urethra. Color Doppler [Figure - 2]a,b showed a 14mm sac with arterial flow in the right corpora cavernosa, being fed by the deep artery of penis. The venous sinusoids of the corpora were distended and the spectral pattern in the deep artery of penis was highly pulsatile, reversing during the diastolic phase

An angiogram [Figure - 3] with selective injections into both internal iliac arteries, showed a prominent right internal pudendal artery and deep penile artery terminating in a arteriosinusoidal fistula. An accessory right pudendal artery also supplied the fistula through the transverse perineal branch. The left internal pudendal artery was normal, with no contribution to the fistula.

The right internal pudendal artery was selectively entered using 4F Terumo Glide catheter which was maneuvered into the deep artery of penis [Figure - 4]. The fistula was embolised using Gelfoam pledgets.

The priapism resolved in 48 hours, with mild turgidity persisting for further two days. The Doppler [Figure - 5] showed a thrombosed fistulous sac and resumption of forward flow in the deep artery of penis, in diastole. The urethral stricture was subsequently treated with optical internal urethrotomy and he was taught self-dilatation. He regained potency one month after the procedure.


   Discussion Top


Priapism is persistent erection caused by imbalance between arterial inflow and venous outflow [1],[2]. The commoner venoocclusive type results from prolonged stagnation of blood in the corpora due to inadequate venous outflow, leading to painful erection - secondary to an acidotic hypoxic environment. It is usually caused by hematologic syndromes (sickle cell, leukemia), hypercoagulable states, fat emboli, metastatic disease and metabolic disorders like Fabry's disease. The condition is an emergency and delay in treatment causes corporeal fibrosis and permanent impotence [1],[2].

In contrast, high flow priapism is due to increased arterial inflow caused by trauma to the cavernosal artery or to its helicine branches. Rare instances of idiopathic etiology are reported. This results in an arteriocavernosal fistula with or without a pseudoaneurysm. The erection can occur upto 8 hours after the traumatic event. Since arterial inflow is good, there is no ischaemia - and treatment is not emergent [1],[2].

In view of the above, differentiation between the two conditions is important. In addition to the clinical picture of painless erection with a history of trauma, diagnosis is confirmed by results of gasometry from cavernosal blood aspirate, cavernosography. Colour Duplex Doppler and pudendal angiography [2]. Cavernosal blood gas analysis will reveal values similar to arterial blood. Colour Doppler confirms patency of cavernosal arteries, prominent venous drainage and unilateral / bilateral arteriocavernous fistulae with or without a pseudoaneurysm. The spectral pattern in our patient was highly pulsatile with diastolic reversal, similar to the pattern found in Papaverine induced erection - secondary to the high pressure in the cavernous sinusoids.

Bilateral internal pudendal angiography is the gold standard in diagnosis of this condition - but Colour Doppler is reported to have a sensitivity of 100% and specificity of 73% compared to the angiogram [3].

Treatment of the condition is initially conservative. Mechanical external compression of the perineum, ice packs, corporeal aspiration and irrigation with saline have been tried, beside intracorporeal administration of alpha - agonists and methylene blue - which antagonizes endothelial derived relaxation factor [2]. Recently, Color Doppler guided transperineal mechanical compression of the fistula with the ultrasound probe has been reported to have more success, in contrast to the imprecise pressure applied by blind mechanical compression [4]. However these measures are often unsuccessful and invasive methods are required.

Internal pudendal angiography delineates the fistula with accuracy. Embolisation of the Deep artery of penis (cavernosal artery) is the treatment of choice, but controversy exists as to the choice of embolic material. Autologous blood clot has been recommended as the embolic agent of choice since it occludes the fistula, while preserving potency as the vessel recanalizes [1],[2],[5]. This is especially relevant in bilateral pudendal artery embolisation. Other researchers have used Gelfoam pledgets - however studies have shown Gelfoam can also cause panarteritis and disruption of the intima [1],[2]. Iso-butyl-cyanoacrylate has been used rarely [6], but is not favored since it occludes the deep artery of penis permanently. Recently, several reports of the use of micro coils indicate that superselective placement of coils do not affect the return of potency [7].

In our patient, we used Gelfoam pledgets since the fistula was unilateral, with the intention of using a permanent occluder if the fistula recurred. Reports of local complications are rare - with one isolated report of a perineal abscess [8]. Residual cavernous turgidity can be treated with intracavernous streptokinase irrigation. In a series report of long term follow up of high flow priapism treated by embolisation [9], in one out of nine patients, repeated embolisation procedures failed and surgery was resorted to. Fistula recurrence requiring re-embolisation was reported in 4 out of 9 patients. Sexual function was preserved in 80%.

Patients in whom embolisation fails, have to undergo surgery [10]. There are two surgical approaches - extracorporeal and transcorporeal. Extra corporeal ligation of the cavernosal artery poses fewer risks - but can have arteriogenic impotence as a sequela. Transcorporeal resection may be required in arterial priapism of long duration, especially if a vascular pseudocapsule forms around the fistula - however damage to the corporal venoocclusive mechanism can result in venogenic impotence.

Bilateral pudendal artery embolisation can result in temporary loss of potency, which may take upto 5 months to resolve [1].

In summary, high flow post traumatic priapism is a condition elegantly managed by transarterial embolisation.

 
   References Top

1.Bertino RE, Castaneda F, Brady TM, Herrera MA, Castaneda - Zuniga WR Interventional Therapy in the treatment of impotence and high flow priapism. In:Castaneda-Zuniga WR, Tadavarthy SM Qian Z, Ferral H, Maynar M, eds. Interventional Radiology, 3rd ed. William and Wilkins, 1997-309-311.  Back to cited text no. 1    
2.Colombo F, Lovaria A, Saccheri S, Pozzoni F. Montanaris E. Arterial Embolisation in the treatment of posttraumatic priapism. Ann Urol 1999;33(3):210-218.  Back to cited text no. 2    
3.Hakim LS, Kulaksizoglu H, Mulligan R, Greenfield A, Goldstein I. Evolving concepts in diagnosis and treatment of arterial high flow priapism. J Urol 19967; 155(2):541-548.  Back to cited text no. 3    
4.Sancak T, Conkbayir I. Post traumatic high flow priapism: management by superselective transcatheter autologous clot embolisation and duplex sonography guided compression. J. Clin Ultrasound 2001;29(6):349-353  Back to cited text no. 4    
5.Ravi R. Baijal SS, Roy S. Embolotherapy of priapism. Arch Esp Urol 1992; 45(6):587-588.  Back to cited text no. 5    
6.Numan F, Cakirer S, Islak C et al . Posttraumatic high flow priapism treated by N-butyl-cyanoacrylate embolisation. Cardiovasc Intervent Radiol 1996; 19(4); 278-280.  Back to cited text no. 6    
7.Gujral S, MacDonagh RP, Cavanagh PM. Bilateral Superselective arterial microcoil embolisation in delayed posttraumatic high flow priapism. Postgrad Med J 2001; 77 (905); 193-194.  Back to cited text no. 7    
8.Sandock DS, Seftel AD, Herbener TE, Goldstein I, Greenfield AJ. Perineal abscess after embolisation for high flow priapism. Urology 1996; 48 (2): 308-311.  Back to cited text no. 8    
9.Ciampalini S. Savoca G, Buttazzi L et al . High flow priapism: Treatment and Long term follow up. Urology 2002; 59(1): 110-113  Back to cited text no. 9    
10.Shapiro RH, Berger RE. Posttraumatic priapism treated with selective cavernosal artery ligation. Urology 1997;49(4):638-643.  Back to cited text no. 10    

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Correspondence Address:
N K Prabhu
Department of Radiology, Amrita Institute of Medical Sciences, Amrita Lane, Elamakkara, Cochin-682026, Kerala
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]



 

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    Introduction
    Case Report
    Discussion
    References
    Article Figures

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