Cardiovasc Intervent Radiol (1996) 19:278–280
CardioVascular
Posttraumatic High-Flow Priapism Treated by
N-Butyl-Cyanoacrylate Embolization
Füruzan Numan,1 Sinan Çakırer,1 Civan Işlak,1 Gündüz Öğüt,1 Ateş Kadıoğlu,2 Selahittin Çayan,2
Sedat Tellaloğlu2
1
Department of Radiology, Istanbul University, Cerrahpaşa Medical Faculty, 34300 Cerrahpaşa, Istanbul, Turkey
2
Department of Urology, Istanbul University, Istanbul Medical Faculty, 34330 Çapa, Istanbul, Turkey
Abstract
A patient with high-flow priapism was treated by
transcatheter embolization of a posttraumatic left
cavernosal arteriovenous fistula using N-butyl-cya-
noacrylate (NBCA), resulting in complete detumes-
cence. Erectile function has been preserved during a
3-month follow-up. Only two patients with NBCA
embolization for high-flow priapism have been re-
ported previously.
Key words: Penis—Priapism—Cavernosal arteriove-
nous fistula—Embolization, therapeutic
Priapism can be defined as prolonged penile erection
unrelated to sexual desire, often causing pain. Two var-
iants of priapism have been described by Hauri et al.
[1]: the more frequent type is the low-flow veno-occlu-
sive (ischemic) priapism; the less common form is the
high-flow arterial (nonischemic) priapism. Injury to a
cavernosal artery, usually after perineal or direct penile
trauma, results in uncontrolled, high arterial inflow into
the corpora cavernosa. The patients have prolonged and
painless erection with a lower incidence of permanent
impotence than those with low-flow priapism [1–3].
We describe the diagnosis and embolization therapy of
a patient presenting with posttraumatic high-flow pri-
apism.
Case Report
A 72-year-old white man presented to the hospital after a traffic ac-
cident causing a straddle injury to the perineum. Examination in the
emergency room showed a bruised perineum, and radiography con-
Correspondence to: Prof. Dr. F. Numan
sv 4k06 0006 Mp 278 Monday May 13 04:37 PM SV-CVIR (v. 19, #3) 0006 (2273)
and Interventional
Radiology
q Springer-Verlag New York Inc. 1996
firmed pelvic diasthasis (Fig. 1). On the 14th day after trauma, uro-
logical examination revealed a flaccid edematous penis, and a small
necrotic area near the left side of the glans. On the 16th day, the
patient developed sustained penile erection with hard corpora cav-
ernosa and a somewhat soft glans. Blood gas determination of a blood
sample from the left corpus cavernosum showed a bicarbonate con-
centration of 25 mEq/L, an oxygen pressure of 87 mmHg, and a CO2
pressure of 37 mmHg. Color Doppler ultrasound revealed turbulent
flow within the left corpus cavernosum due to a cavernosal arterio-
venous fistula (AVF). The diagnosis was high-flow priapism resulting
from a cavernosal artery injury.
Five days later, angiography was performed via the left common
femoral artery into which a 5 Fr introducer sheath was placed. A 4
Fr end-hole catheter with a 907 curve (Cathéter Picard 4 Fr, Balt,
Montmorency, France) was passed into the left internal pudendal
artery. Angiography demonstrated a cavernosal AVF at the base of
the left corpus cavernosum (Fig. 1). A FASTracker catheter-10 (Tar-
get Therapeutics, Fremont, CA, USA) was introduced through the
diagnostic guiding catheter until it was selectively placed in the fis-
tula. For the subsequent embolization, 0.5 ml of N-butyl-cyanoac-
rylate (NBCA) (Histoacryl blau, Braun, Melsungen, Germany) was
mixed with lipiodol in a 1:3 ratio so that it was fluoroscopically
visible and the lipiodol somewhat delayed the polymerization of
NBCA. Embolization with that mixture produced an immediate oc-
clusion of the fistula (Fig. 2). The penis was totally flaccid 5 hr after
the procedure. In order to prevent nocturnal erections, a penile elastic
bandage was applied. By 2 months after the procedure, the patient’s
erectile activity had returned and at the end of the third month the
patient had resumed his usual sexual activity.
Discussion
Arterial high-flow priapism results from a cavernosal
AVF, causing unregulated, continuous arterial inflow
to the lacunar spaces and bypassing the high-resistance
helicine arteries. This condition, combined with incom-
plete compression of subtunical venules against the
tunica itself, results in a reduction of venous return. The
etiology is a lacerated cavernous artery secondary to
blunt perineal or penetrating penile trauma [1, 3–6].
Diagnosis and treatment of low-flow venoocclusive
priapism are well established [4]; that of arterial pria-
F. Numan et al.: NBCA Embolization for High-Flow Priapism 279

Table 1. Review of 30 case reports of high flow priapism and treatment

Yr/reference Age (yrs) Type of injury Duration of priapism Evaluation Treatment Result

1960 [2] 22 Unknown 24 hours Corporeal exploration Open ligation Impotent

1977 [9] 26 Perineal 7 days IPA ACE Potent
1978 [14] 25 Perineal 7 days IPA Open ligation Impotent
1979 [10] 49 Perineal 9 days IPA ACE Potent
1980 [16] 36 Unknown 4 days IPA ACE Potent
1981 [17] 17 Perineal 3 days IPA AC / gelatin sponge E Potent
1983 [1] Unknown Perineal 6 months IPA Open ligation Potent
1983 [18] 74 Unknown 2 days IPA ACE Potent
1984 [19] 65 Unknown 12 hours IPA ACE Partial erection
1990 [5] 37 Perineal 6 days IPA ACE Potent
50 Penile 6 days IPA ACE Potent
1990 [3] 34 Perineal 8 days IPA ACE Potent
52 Penile 5 days IPA ACE Potent
1991 [20] 21 Perineal 8 hours IPA Gelatin sponge E Potent
1992 [6] 7 Perineal 9 days IPA ACE Potent
1993 [8] 32 Perineal 17 days IPA Open ligation Partial erection
17 Perineal 15 months IPA Coil E Potent
32 Perineal 36 months IPA Open ligation Partial erection
1993 [15] 30 Perineal 7 months US Open ligation Partial erection
1993 [7] 28 Perineal Unknown IPA Open ligation Potent
1994 [12] 37 Perineal 25 days IPA ACE Potent
23 Perineal 4 days IPA ACE Potent
11 Perineal 5 days IPA, US ACE Potent
30 Perineal 126 days IPA, US ACE Potent
21 Perineal 1 month IPA, US ACE Potent
35 Perineal 49 days IPA ACE Potent
50 Penile 20 days IPA ACE No followup
1994 [21] 21 Perineal 2 months IPA, US NBCA E Potent
33 Perineal 1 month IPA, US NBCA E Potent
1994 [22] 27 Perineal 4 days IPA, US Gelatin sponge E Potent
Present case 72 Perineal 5 days IPA, US NBCA E Potent

IPA Å internal pudendal arteriography; US Å Doppler sonography; AC Å autologous clot; E Å transcatheter embolization

pism remain controversial [3, 7–9]. Diagnosis of the
latter is usually based on a history of penile or perineal
trauma associated with delayed but persistent painless
erection, aspiration of bright red corporeal blood, and
normal intracorporeal blood gas [3, 8, 10]. Color Dopp-
ler sonography constitutes a rapid noninvasive method
for diagnosis and localization of the fistula [3, 8, 11,
12]. However, selective internal pudendal arteriogra-
phy should be performed to define the lacerated branch
of the cavernosal artery and the feasibility of selective
arterial embolization [2, 5, 7, 9, 13, 14].
Proposed therapeutic modalities have been me-
chanical (sustained perineal compression), pharmaco-
logical (intracavernous administration of a-adrenergic
agonists or methylene blue), surgical (ligation of the
internal pudendal artery), and radiological (selective
transcatheter embolization) [12].
Thirty cases of high-flow priapism have been doc-
umented in the literature; twenty-eight have been con-
firmed arteriographically (Table 1). In 1977 Wear et al.
[9] achieved the first transcatheter internal pudendal
artery embolization with autologous clot to manage
high-flow priapism. Among the reported 30 patients, 7
were treated by surgical ligation of the internal puden-
dal artery [1, 2, 7, 8, 14, 15] and the remainder by
transcatheter embolization [3, 5, 6, 9, 10, 12, 16–22].
With the exception of two patients who underwent em-
bolization with NBCA [21] and one with coils [8], ab-
sorbable embolic materials (gelatin sponge and
autologous clot) were used. The patients treated with
NBCA underwent selective embolization of the cav-
ernosal AVF [21]; all others had selective embolization
of the ipsilateral internal pudendal artery or the caver-
nosal artery.
NBCA quickly polymerizes in contact with an ionic
medium such as blood, and strongly adheres to the tis-
sue, resulting in rapid and permanent occlusion. The
interventional radiologist must be experienced in its use
to avoid serious complications. It is injected through
the catheter, which is filled with a nonionic medium
such as 5% dextrose in water. The catheter is pulled
back immediately following the injection of NBCA to
avoid inadvertent adherence to the tissue. In our pa-
tient, the tip of the embolization catheter was placed
directly in the cavernosal AVF. We prefer the FAS-
Tracker catheter as it easily advances into very small
diameter vessels with no or minimal arterial spasm be-
cause of its hydrophilic coatings.
In conclusion, the availability of newer catheteri-
zation methods and embolic materials provides an ef-

sv 4k06 0006 Mp 279 Monday May 13 04:37 PM SV-CVIR (v. 19, #3) 0006 (2273)
280
Fig. 1. Selective left internal pudendal arteriogram shows left caver-
nosal arteriovenous fistula at the base of the left corpus cavernosum
(arrowhead) with characteristic cavernous arterial blush.
fective treatment of high-flow priapism by subselective
targeted embolization. The preferred embolization ma-
terials of reported cases have been absorbable agents,
mostly autologous blood clot, that provide temporary
occlusion with no risk of permanent impotence. Treat-
ment failures have to be expected. In our opinion, em-
bolization procedures should be directed very
selectively to the site of laceration, e.g., into the cav-
ernosal AVF, leaving other distal branches of the in-
ternal pudendal artery intact. The procedure should be
performed by experienced interventional radiologists,
using embolic materials that provide permanent occlu-
sion.
References
1. Hauri D, Spycher M, Brühlmann W (1983) Erection and pria-
pism: A new physiopathological concept. Urol Int 38:138–141
2. Burt FR, Schirmer HK, Scott WW (1960) A new concept in the
management of priapism. J Urol 83:60–61
3. Witt MA, Goldstein I, De Tejada IS, Greenfield A, Krane RJ
(1990) Traumatic laceration of intracavernosal arteries: The
pathophysiology of nonischemic, high flow, arterial priapism. J
Urol 143:129–134
4. Lue TF, Hellstrom WJG, McAninch JW, Tanagho EA (1986)
Priapism: A refined approach to diagnosis and treatment. J Urol
136:104–108
5. Walker TG, Crant PW, Goldstein I, Krane RJ, Greenfield AJ
(1990) ‘‘High-flow’’ priapism: Treatment with superselective
transcatheter embolization. Radiology 174:1053–1056
6. Visvanathan K, Burrows PE, Schillinger JF, Khoury AE (1992)
Posttraumatic arterial priapism in a 7-year-old boy: Successful
management by percutaneous transcatheter embolization. J Urol
148:382–383
7. Ricciardi R, Bhatt GM, Cynamon J, Bakal CW, Melman A
(1993) Delayed high flow priapism: Pathophysiology and man-
agement. J Urol 149:119–121
sv 4k06 0006 Mp 280 Monday May 13 04:37 PM SV-CVIR (v. 19, #3) 0006 (2273)
F. Numan et al.: NBCA Embolization for High-Flow Priapism
Fig. 2. Postembolization selective left internal pudendal arteriogram
shows that the fistula has closed (arrowhead).
8. Brock G, Breza J, Lue TF, Tanagho EA (1993) High flow pria-
pism: A spectrum of disease. J Urol 150:968–971
9. Wear JB, Crummy AB, Munson BO (1977) A new approach to
the treatment of priapism. J Urol 117:252–254
10. Crummy AB, Ishizaka J, Madsen PO (1979) Posttraumatic pri-
apism: Successful treatment with autologous clot embolization.
AJR 133:329–332
11. Gudinchet D, Fournier D, Jichlinski P, Meyrat B (1992) Trau-
matic priapism in a child: Evaluation with color flow Doppler
sonography. J Urol 148:380–383
12. Bastuba MD, De Tejada IS, Dinlenc CZ, Sarazen A, Krane RJ,
Goldstein I (1994) Arterial priapism: Diagnosis, treatment and
long-term followup. J Urol 151:1231–1237
13. Bookstein JJ (1988) Penile angiography: The last angiographic
frontier. AJR 150:47–51
14. Wheeler GW, Simmons CR (1973) Angiography in posttrau-
matic priapism: A case report. AJR 119:619–620
15. Harding JR, Hollander JB, Bendick PJ (1993) Chronic priapism
secondary to a traumatic arteriovenous fistula of the corpus cav-
ernosum. J Urol 150:1504–1506
16. Carmignani G, Belgrano E, Puppo P, Cichero A, Quattrini S
(1980) Idiopathic priapism successfully treated by unilateral em-
bolization of internal pudendal artery. J Urol 124:553–556
17. McLeod RE, Clayden GR, Bonnell G (1981) Post-traumatic pri-
apism: Successful treatment by percutaneous catheter emboli-
zation. J Can Assoc Radiol 32:238–240
18. Puppo P, Belgrano E, Quattrini S, Fabbro V, Rebetto U, Giuliani
L (1983) Treatment of priapism by transcatheter embolization of
internal pudendal arteries. Urol Radiol 5:261–263
19. Belgrano E, Puppo P, Quattrini S, Trombetta C, Bottino P, Giu-
liani L (1984) Percutaneous temporary embolization of the in-
ternal pudendal arteries in idiopathic priapism: 2 additional
cases. J Urol 131:756–758
20. Steers WD, Selby JB (1991) Use of methylene blue and selective
embolization of the pudendal artery for high flow priapism refractory
to medical and surgical treatments. J Urol 146:1361–1363
21. Gonzalez EA, Pamplona M, Rodriguez A, Garcia-Hidalgo E, Nunez
V, Leiva O (1994) High flow priapism after blunt perineal trauma:
Resolution with bucrylate embolization. J Urol 151:426–428
22. Ming-Xian J, Neng-Shu H, Ping W, Gui C (1994) Use of selec-
tive embolization of the bilateral cavernous arteries for posttrau-
matic arterial priapism. J Urol 151:1641–1642