Managing the Emergency of

Priapism
Ricky Adriansjah,dr,SpU(K)

SMF Urologi, Dept. Bedah

Fakultas Kedokteran Universitas Padjadjaran
Rumah Sakit Hasan Sadikin Bandung
INTRODUCTION

 The term priapism has its origin in reference

to the Greek god : Priapus, who was
worshipped as a god of fertility and
protector of horticulture.
 This painting was discovered in the wall of
a temple in Pompeii. It shows Priapos
“weighting his erection”
The anatomy

Cellgoj et al.2016.Anatomy and physiology of erection, ejaculation, and orgasm.

Normal erection versus priapism

Anele UA. 2015. Molecular Pathophysiology of Priapism.

ERECTION STATE

Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;50

 FLACCID STATE

Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;48

PENILE
ERECTION
MECHANISM

Fazio, L. Erectile dysfunction:

management update.
Canadian Medical
Association Journal 2004.
170(9), 1429–1437.
Is priapism an emergency case?

 Priapism is a full or partial erection that continues more than 4 hours beyond
sexual stimulation and orgasm or is unrelated to sexual stimulation.
 Priapism is an uncommon urological emergency that can lead to permanent
impotence

Classification :
 Ischemic Priapism (Veno-Occlusive, Low-Flow)
 Stuttering Priapism (Intermittent)
 Nonischemic Priapism (Arterial, High-Flow)

Campbell walsh urology 11th edition page 669

Ischemic Priapism

 Persistent erection marked by rigidity of the CC, with little or no

cavernous arterial inflow.
 Accounting for more than 95% of all priapism episodes
 Emergency medical intervention is required to minimise irreversible
consequences, such as smooth muscle necrosis, corporal fibrosis
and the development of permanent ED
 Duration of ischaemic priapism = Development of ED

Campbell walsh urology 11th edition page 670; EAU 2019 male sexual dysfunction page 45
Stuttering Priapism

 A pattern of recurrence. The term has traditionally described

recurrent prolonged and painful erections in men with Sickell Cell
Disease.
 Characterised by repetitive and painful episodes of prolonged
erections

Campbell walsh urology 11th edition page 670;

Non-ischemic Priapism

 Persistent erection caused by unregulated cavernous arterial inflow.

 The corpora are tumescent but not rigid and the penis is not painful
 The most frequent cause of non-ischaemic priapism is blunt perineal
or penile trauma
 The management of non-ischaemic priapism is not an emergency
because the corpus cavernosum does not contain ischaemic blood

Campbell walsh urology 11th edition page 670; EAU 2019 male sexual dysfunction page 54-55
Campbell walsh urology 11th ed
How to recognize?

95%
Because 95% of prolonged erection is ischemic priapism, then early diagnosis and
proper treatment is the key of management of priapism
The fundamental key

 History
 Physical Examination
 Laboratory test
 corpus cavernosum blood gas analyses
 complete blood count (CBC)
 WBC count with blood cell differential,
 platelet count
 Coagulation profile
 Imaging (Penile Doppler US)

Muneer A, Alnajjar HM and Ralph D. Recent advances in the management of priapism F1000Research 2018,
7(F1000 Faculty Rev):37 ; Campbell walsh urology 11th ed
Element in taking the history of
priapism
 Duration of erection
 Presence of pain
 Previous episodes of priapism and method of treatment
 Baseline erectile function
 Use of any erectogenic therapies (both prescription and nutritional
supplements)
 Medications and recreational drugs
 Sickle cell disease, hemoglobinopathies, hypercoagulable states
 Trauma to the pelvis, perineum, or penis

Muneer A, Alnajjar HM and Ralph D. Recent advances in the management of priapism F1000Research 2018, 7(F1000
Faculty Rev):37 ; Priapism. Campbell walsh urology 11th ed
Key finding in priapism

Muneer A, Alnajjar HM and Ralph D. Recent advances in the management of priapism F1000Research 2018, 7(F1000 Faculty
Rev):37 ; Priapism. Campbell walsh urology 11th ed
Typical Blood gas value

Justin D. La Favor, Zongming Fu, Vidya Venkatraman. Molecular Profile of Priapism Associated with Low Nitric Oxide
Bioavailability. 2018. J. Proteome Res. ; Campbell walsh urology 11th ed
Penile Doppler ultrasound
 Color Doppler Ultrasound (CDU) is an adjunct to the corporal aspirate in
differentiating ischemic from nonischemic priapism.
 Ischemic priapism will have no blood flow in the cavernous arteries
 Nonischemic priapism have normal to high blood flow velocities
 CDU imaging should include corporal shaft and transperineal assessment of the
crural bodies when there is a history of penile trauma or straddle injury.

Muneer A, Alnajjar HM and Ralph D. Recent advances in the management of priapism F1000Research 2018, 7(F1000 Faculty
Rev):37 ; Priapism. Campbell walsh urology 11th ed
How to manage it?

The aim of treatment is the immediate resolution of the painful erection and the
preservation of cavernosal smooth muscle function in order to prevent cavernosal
fibrosis, which can lead to penile shortening and permanent erectile dysfunction.

Muneer A, Alnajjar HM and Ralph D. Recent advances in the management of priapism F1000Research 2018, 7(F1000
Faculty Rev):37
Treatment of ischaemic priapism
Muneer A, Alnajjar HM and Ralph D. Recent advances in the management of priapism F1000Research 2018, 7(F1000
Faculty Rev):37 ; Priapism. Campbell walsh urology 11th ed
Medical treatment of ischemic
priapism
Surgical Intervention

 Shunt surgery allows diversion of blood from the corpus cavernosum into
another area
 Using distal shunts and proximal shunts in situations where aspiration
and instillation of pharmacological agents fail
 Technique :
 Winter shunt
 Ebbehoj technique
 T shunt
 Al-Ghorab
 Burnett technique
 Quakle’s technique
 Grayhack’s procedure
Asif Muneer. Comparison of EAU and UK guidelines on priapism. 2018. Journal of Clinical Urology.
Sacher’s technique: This comprises a bilateral performance of the Quackles
procedure, together with staggered corpora cavernosa-corpus spongiosum
shunts to reduce the risk of urethral stricture adjacent to the shunts
RSHS Data 2008-2018

 Total number of patients : 16

 16-58 yo
 Duration : 24-260 hrs
 Low Flow 15, High flow 1
 Management : 15 Winter’s procedure, 1 conservative
 Etiology : 13 CML, Idiop 2 ED inj drug
THANK YOU